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08 I I case report _ open-apex retreatment guided through the wide canal to the open apex with pre-fitted pluggers, creating a platform for the safe adaptation of the MTA plug (Fig. 4b). White MTA (DENTSPLY Maillefer) was mixed with sterile water until a thick consistency was achieved. MTA material was carried inside the root canal with an appropriate amalgam carrier used as MTA carrier (Fig. 5a). Pre-fitted pluggers were used with slight apical pressure to push the MTA material to the apex until the material was adapted to the apical anatomy of the open apex that was plugged with the ab- sorbable sponge (Fig. 5b). Adaptation of the material was assessed visually under x16 magnification and radiographically until the plug filled the apical 5mm ofthewidecanal(Figs.6a&b).Afterthecompletionof the procedure, a wet cotton pellet was placed in con- tactwiththeMTA,andtemporarisationwasachieved withCavitG(3MESPE).Thepatientwasreferredback tohisgeneralpractitionerforappropriaterestoration and came back to our practice for a follow-up exami- nationaftersixmonths(Figs.6c&d). _Discussion A major problem in performing endodontics in immature teeth with necrotic pulp and wide-open apices is obtaining an optimal seal of the root-canal system. For more than 40 years, such cases were ap- proachedclinicallywithapexification.1 Theinitialaim of the procedure was to limit the bacterial infection and create an environment conductive to the pro- duction of a mineralised tissue barrier or root-end formation at the immature root apex. Ca(OH)2 was commonly used for this purpose. Despite the popu- larity of this technique, inherent disadvantages exist.Variabilityoftreatmenttime,unpredictabilityof apicalclosure,difficultyinpatientfollow-up,suscep- tibilitytofractureandreinfectionarethemaindisad- vantages of the procedure. All these disadvantages lead us to continue the search for procedures and materialsthatmayallowforcontinuedapicalclosure in teeth with immature apices. Although research on therevascularisationproceduresofthenecroticopen apex is promising,10 the MTA apical plug technique is considered a good alternative treatment procedure. Its physical and chemical properties make MTA a goodpotentialapicalbarrier,includingitssealingand antimicrobial ability, marginal adaptation and bio- compatibility.6 However, the material manipulation and delivery technique of the procedure pose great clinical challenges. The aim of the present article was todescribetheMTAapicalplugtechniquesystemati- cally, and to provide tips and hints for the successful management of challenging open-apex retreatment cases. Although extruded beyond the apex materials, which may indicate surgical treatment planning, an orthograde retreatment procedure was followed in the present case. Extruded materials were success- roots4_2010 Fig. 4a_Gelatine sponge cut to fit the canal. Fig. 4b_Gelatine sponge in place. Figs. 5a & b_MTA carried inside the canal (a), and condensed to length (b). Fig. 4a Fig. 4b Fig. 5a Fig. 5b